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Sex Transm Dis. Author manuscript; available in PMC 2024 August 01.
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Published in final edited form as:

Sex Transm Dis. 2023 August 01; 50(8): 467–471. doi:10.1097/OLQ.0000000000001814.

A Sore Subject?: An Examination of National Case-Based

Chancroid Surveillance
Yasmin P. Ogale, PhD, MSPH,
Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services,
and Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention
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Alison D. Ridpath, MD, MPH,

Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention

Elizabeth Torrone, PhD, MSPH,

Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention

Laura A. S. Quilter, MD, MPH,

Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Centers for Disease Control and Prevention

Jeremy A. Grey, PhD

Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention,
Author Manuscript

Centers for Disease Control and Prevention

Abstract
Background: Chancroid has been a nationally notifiable condition in the United States since
1944, with cases reported to Centers Disease Control and Prevention through the National
Notifiable Diseases Surveillance System (NNDSS). Although frequently reported during the
1940s, <20 cases have been reported annually since 2011. We assessed the performance and
utility of national case-based chancroid surveillance.

Methods: We reviewed the literature to contextualize chancroid surveillance through NNDSS.

We then assessed 4 system attributes, including data quality, sensitivity, usefulness, and
representativeness: we reviewed chancroid cases reported during 2011–2020, conducted interviews
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with a) STD programs reporting ≥1 case in 2019 or 2020 (n = 9) and b) CDC subject matter
experts (n=10), and reviewed published communicable disease reporting laws.

Results: Chancroid diagnostic testing is limited, which affects the surveillance case definition.
National case-based surveillance has poor data quality; of the 2019 and preliminary 2020 cases
(n = 14), only 3 were verified by jurisdictions as chancroid cases. STD programs report the

Corresponding author: Yasmin P. Ogale, 302-588-0608, kzi3@cdc.gov; 1600 Clifton Road NE, Mailstop US12-2, Atlanta, GA 30333,
USA.
Conflict of Interest Statement: No conflict of interest exists. The findings and conclusions in this report are those of the authors and do
not necessarily represent the official position of the Centers for Disease Control and Prevention.
 Ogale et al. Page 2

system has low sensitivity given limited clinician knowledge and resources; experts report the
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system is not useful in guiding national control efforts. Review of reporting laws revealed it is not
representative, as chancroid is not a reportable condition nationwide.

Conclusions: Critical review of system attributes suggest that national case-based chancroid
surveillance data have limited ability to help describe and monitor national trends, and chancroid’s
inclusion on the national notifiable list might need to be reconsidered. Alternative strategies might
be needed to monitor national chancroid burden.
Short Summary
We assessed the utility of national case-based chancroid surveillance in the United States by
examining the sensitivity, data quality, usefulness, and representativeness of the surveillance
system.
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Keywords
STI; STD; chancroid; surveillance; Haemophilus ducreyi

Introduction
Chancroid is a sexually transmitted disease (STD) caused by infection with Haemophilus
ducreyi, a fastidious, gram-negative bacteria that results in genital ulcer disease;
transmission occurs through sexual contact, and humans are the only host. While a
low infectious dose is thought to be needed for infection, sustained transmission within
communities has historically involved dense sexual networks, such as those among sex
workers.1 The clinical presentation of chancroid includes painful anogenital ulcers and
buboes (very inflamed and swollen lymph nodes) in the groin region. Buboes can take
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weeks to months to resolve if not treated2 and can occur in up to 50% of cases.3 Symptoms
typically do not lead to hospitalization or death but might result in long-term sequelae such
as genital scarring and rectal or uro-genital fistulas. Additionally, the infection can facilitate
the transmission and acquisition of HIV.4,5 Fortunately, multiple effective antimicrobials
for the treatment of chancroid are available, which can cure the infection, resolve clinical
symptoms, and prevent transmission to others.6

In the United States, chancroid has been a nationally notifiable condition since 1944,
with case notifications provided to the Centers for Disease Prevention and Control (CDC)
through the National Notifiable Diseases Surveillance System (NNDSS). Cases of chancroid
reported through NNDSS peaked in 1947 (N = 9,515 cases) and then rapidly declined
through 1959 (N = 1,537 cases), possibly because of increasing use of antimicrobials
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like sulfonamides and penicillin that were introduced in the late 1930s and early 1940s
(Fig. 1).7,8 Significant social changes, including reduced migration and improved economic
options for women, and earlier changes in sex work communities might have also
contributed to the decline.8 A number of localized outbreaks, most of which were linked
to commercial sex work, were identified in the United States during 1981–1990.9,10 Since
2011, national case counts have declined to <20 cases annually. Because only diagnosed
and reported cases can be included in NNDSS, it is likely that national trends are heavily

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influenced by changes in diagnostic capacity, programmatic response, and adherence to case

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definitions and reporting practices. Other than NNDSS, there are no national surveillance
systems in place to monitor trends in chancroid; therefore, there are no US chancroid
prevalence estimates and most recently published studies are limited to case reports.11-13

There has been no documented evaluation of national case-based chancroid reporting since
the surveillance case definition was last updated in 1996. To examine the performance of
ongoing national case-based chancroid surveillance and identify areas for improvement,
we conducted an evaluation of chancroid surveillance through NNDSS by describing the
surveillance system, followed by a critical review of the system’s attributes based on
available evidence and key informant interviews.

Materials and Methods

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To better understand the context and issues that might affect chancroid surveillance, we
first reviewed the literature on current chancroid diagnostic capacity, as well as changes in
the surveillance case definition over time. We then assessed 4 system attributes of national
case-based surveillance through NNDSS, including data quality, sensitivity, usefulness, and
representativeness, using available evidence and key informant interviews. To assess data
quality, we analyzed chancroid case notifications provided through NNDSS during 2011–
2020 (2020 data preliminary as of September 16, 2021) and calculated the proportion
of cases reported with a case status of “probable” or “confirmed” in the current case
definition. For jurisdictions reporting ≥1 cases in 2019 or 2020 (n = 9), we conducted
phone interviews with key informants (state and local STD program managers to verify
if reported cases met the current chancroid case definition. To assess sensitivity, we also
asked informants to describe local reporting practices and control efforts for suspected
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chancroid cases. Additionally, we conducted key informant interviews with 10 CDC subject
matter experts involved in national chancroid surveillance, including STD program officers
and surveillance leads, to understand national uses of case data and assess usefulness;
key informants were purposefully selected based on their subject matter expertise in STD
surveillance or experience working with state and local STD programs. Finally, to assess
representativeness, we reviewed the health department websites for all 50 U.S. states and the
District of Columbia (DC) and abstracted published communicable disease reporting laws
and guidance to investigate whether chancroid is a reportable condition in all areas.

Results
Literature Review: Contextual Issues Affecting Chancroid Surveillance
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Laboratory and Clinical Diagnosis—Several methods exist for the laboratory diagnosis
of chancroid, including microscopy, in vitro culture, and DNA amplification techniques;
however, each has its own challenges. Regarding microscopy, studies show that Gram stain
of clinical material has low sensitivity and specificity and does not compare favorably
with either culture-proven or clinically-diagnosed chancroid cases in most studies.14,15
As such, microscopy is not currently recommended to diagnose chancroid.1,15 In vitro
culture for H. ducreyi is required for a definitive diagnosis of chancroid in the clinical
setting.14-16 Culture has a high specificity, but low sensitivity (<75% in comparison to

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molecular methods described below).3,14 Further, the culture media required to grow H.
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ducreyi are not commercially available in the US and, therefore, culture is not widely
used. More sensitive DNA amplification techniques were introduced during the 1990s and
have improved sensitivity over culture.14 Currently, polymerase chain reaction (PCR) is the
gold standard for chancroid diagnostic testing in the United States; however, because no
molecular assays are FDA-approved for use in the United States, it is infrequently used
(i.e., only clinical labs that have conducted Clinical Laboratory Improvement Amendments
verification studies on genital specimens can use PCR for diagnosing chancroid).

Chancroid is clinically characterized by painful genital ulceration and inflammatory inguinal

adenopathy. In low-resource settings, a clinical diagnosis of chancroid based on patient
history and physical exam findings can be made if culture media for H. ducreyi are not
available (i.e., syndromic management).1 However, the clinical presentation of chancroid
is similar to other genital ulcerative infections like herpes and syphilis, making a clinical
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diagnosis of chancroid challenging. Studies have shown that clinical diagnosis accuracy for
chancroid ranges from 33% to 80%.14 Laboratory exclusion of these other STDs should
inform clinical diagnoses, but these diagnostic tests also have limitations or might not
always be performed.10

Surveillance Case Definition and NNDSS Case Notification—Surveillance

case definitions are developed and approved by the Council of State and Territorial
Epidemiologists (CSTE) and are recommended for use by all states for local and national
reporting. Case definitions can change and CSTE last updated the chancroid case definition
in 1996. The current surveillance case definition aligns with the current clinical case
definition. The surveillance case definition provides a definition for both confirmed and
probable cases,17 and is based the following clinical and laboratory criteria:
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Confirmed: A clinically compatible case that is laboratory confirmed by isolation of H.

ducreyi from a clinical specimen (i.e., culture positive).

Probable: A clinically compatible case with

• no evidence of Treponema pallidum infection by darkfield microscopic

examination of ulcer exudate or by a serologic test for syphilis performed ≥7
days after onset of ulcers; and

• either a clinical presentation of the ulcer(s) not typical of disease caused by

herpes simplex virus (HSV) or a culture negative for HSV.

NNDSS currently serves as the national surveillance system for nationally notifiable
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conditions in the United States and uses surveillance case definitions of nationally notifiable
conditions to monitor trends. Extensive documentation is provided to states on the standards
and requirements for sending case notifications for national surveillance.18 When states
identify a surveillance case of chancroid through local laboratory or provider reporting, they
send the case notification electronically to CDC through NNDSS; states are encouraged
to send data at least weekly. As NNDSS includes a variety of conditions, the case
status options available in NNDSS (i.e., confirmed, probable, suspect, or unknown) are

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broader than what is valid for chancroid (i.e., confirmed or probable). Per the CSTE
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case definition for chancroid, case notifications should be sent with available demographic
information (e.g., age, sex, race/ethnicity) and case status (probable or confirmed).
Additional information, including HIV status, history of exchanging sex for drugs or money,
sex of sex partners, and substance use, can be included in the chancroid case notification but
they are not required variables. All case reports received through NNDSS are accepted and
counted, regardless of the case status or information provided.

NNDSS Chancroid Case Notifications (2011–2020): Analysis of ‘Probable’ and ‘Confirmed’

Cases
Eighty-one chancroid cases were reported through NNDSS during 2011–2020, with an
average of 8 cases per year (Table 1). Of the 81 cases, 17 (21%) had an invalid case
status (i.e., “suspect” or “unknown”). Information on sex and age was available for most
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cases, but race/ethnicity was missing for one quarter of cases. Likely a result of lack of
case investigations, the majority of cases were missing information on HIV status, sexual
behaviors, and substance use.

Fourteen cases were reported for 2019 (n = 8) and 2020 (n = 6). Based on a review of cases
with key informants during this evaluation, 3 cases were verified by the jurisdiction, 6 were
found to be data entry errors by the jurisdiction (i.e., should have been reported as another
STD), 2 were determined by the jurisdiction not to meet the chancroid case definition, and
3 were not able to be reviewed. None of 6 cases reported during 2020 were verified to meet
the chancroid case definition by the reporting jurisdiction and all were removed prior to
finalization of 2020 NNDSS data in December 2021.

STD Program Manager Interviews: Local Reporting Practices and Control Efforts
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In our key informant interviews, local STD program staff felt that clinician knowledge
of chancroid was limited. Some felt that clinicians were either not aware of chancroid or
did not report it. More specifically, program staff felt that providers could misdiagnose
a chancroid case as some other infection, treat it empirically with an antimicrobial that
resolves symptoms, and therefore, never report the case. These practices further limit the
sensitivity of a case-based surveillance system.

Beyond diagnosis, national case-based surveillance also relies on STD programs to

investigate and follow up on suspected cases to determine if the case meets the surveillance
case definition. Based on key informant interviews, many STD programs prioritize other
STDs for case follow-up, particularly syphilis, so suspected chancroid cases are not always
investigated. This means that, unlike other STDs, cases misreported by clinical providers are
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often not corrected through disease investigation.

Subject Matter Expert Interviews: National Uses of Case Data

During key informant interviews, CDC subject matter experts noted that the national
chancroid case data had limited utility. Chancroid case notifications are included in
annual surveillance reports; however, unlike other nationally notifiable STDs collected
through NNDSS (chlamydia, gonorrhea, and syphilis), there are currently no chancroid

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prevention and control initiatives at the national level. Further, the recent and ongoing
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2018 Strengthening STD Prevention and Control for Health Departments Notice of Funding
Opportunity, which supports health departments to conduct STD surveillance and respond
to STD-related outbreaks across 5 years, does not mention chancroid. Finally, none of the
current measures for monitoring national efforts to reduce the burden and impact of STDs
in the United States (e.g., Healthy People 2030 objectives, Sexually Transmitted Infections
National Strategic Plan indicators) use chancroid case data.19,20

Communicable Disease Reporting Laws and Guidance: Chancroid as a Reportable

Condition
All published communicable disease reporting laws and guidance were abstracted from
health department websites for all 50 U.S. states and DC (websites accessed October 7,
2021). Although the 3 other nationally notifiable STDs that are reported through NNDSS
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(chlamydia, gonorrhea, and syphilis) were identified as reportable conditions in all U.S.
states and DC, chancroid was missing from the published list of reportable conditions in 7
jurisdictions. Therefore, even if case-based reporting was complete in the jurisdictions where
chancroid was reportable, representativeness at the national level would be lacking because
data would not include all states.

Discussion
Critical review of the system’s attributes based on available evidence and key informant
interviews suggest that national case-based chancroid surveillance data have limited ability
to monitor national trends. Although the overall decline in reported chancroid cases in
the US likely reflects a decline in disease incidence (as observed in previous endemic
countries),21,22 these data should be interpreted with caution because H. ducreyi is difficult
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to definitively diagnose: clinical diagnoses may be unreliable due to limitations in diagnostic

testing or because tests are not performed10 and the current surveillance case definition
likely misses most H. ducreyi infections because the laboratory methodology required to
confirm cases (culture) is not readily available.

Our review of recent case notifications found almost a quarter of reported cases in the past
decade did not have a valid case status, suggesting erroneous reporting that could influence
national case rates. Scrutiny of the recently reported cases confirmed only a fraction of
reported cases were correctly reported, further undermining data quality. Additionally, likely
because of the lack of resources for case investigation, few cases were reported with the
clinical and behavioral data needed to fully describe populations being diagnosed with
chancroid. Local STD program manager interviews determined that surveillance often relies
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upon a clinician’s ability to discriminate chancroid from other genital ulcerative diseases
and report cases to local health authorities, which is imperfect and limits the system’s
sensitivity. Furthermore, subject matter expert interviews determined that the national case
notification data have limited usefulness at the national level. Finally, because chancroid
is not a reportable condition in all jurisdictions as per our review, data reported through
NNDSS do not and cannot capture all diagnosed cases in the nation, affecting the system’s
representativeness.

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These findings follow those of similar studies conducted by CDC in the late 1980s and
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early 1990s, prior to the 1996 update to the case definition that is used currently. Similar
to findings from this evaluation, an assessment of chancroid reporting after numerous,
seemingly sporadic outbreaks during 1971–1980 found that chancroid diagnosis and
reporting is unreliable; it is underreported and unrecognized by clinicians in some areas
and often misdiagnosed or misclassified.9 The authors also found it to be overreported in
areas for reasons including clerical reporting mistakes.9 Another study conducted in 1992,
which assessed the decline in cases from the 1980s to 1990s, also found that problems with
accurate diagnosis of chancroid and subsequent reporting of possible cases complicated the
interpretation of surveillance data. In this case, the authors determined that chancroid was
underreported because of the limited availability of culture media for H. ducreyi and a lack
of a probable case definition.10 The latter issue has since been addressed, but the first issue
remains today.
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Although NNDSS is implemented nationwide with a well-established infrastructure that

allows for electronic transmission of case notification data to CDC, findings from this
surveillance evaluation suggest that national case-based chancroid surveillance data continue
to be difficult to interpret. Given the significant limitations of the surveillance system for
chancroid, including poor data quality, reduced sensitivity, limited usefulness, and lack of
representativeness, it is unclear if chancroid should remain on CSTE’s nationally notifiable
condition list (and be monitored at the national level). At the minimum, caveats to national
rate estimates are needed to account for chancroid not being reportable in all jurisdictions,
and data cleaning and quality assurance checks are needed to ensure data quality. It
should be noted, however, that since the completion of this evaluation, CDC’s annual STD
surveillance report was revised as suggested.23 Chancroid data were also added to quarterly
case data review materials, which are provided to jurisdictions to support data cleaning prior
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to NNDSS data close out.

It is possible there is benefit to chancroid remaining on reportable condition lists at the local
or state level. In jurisdictions where it is reportable, a recognized increase in cases locally
might result in a redirection of programmatic resources allowing for investigation of clusters
or outbreaks. However, given the low sensitivity of the case definition, it is possible that
even if it remains a reportable condition, outbreaks may go undetected. Future discussions
are planned with CSTE members and STD programs to better understand the utility of
case-based surveillance for chancroid at the local, state, and national levels. Additionally,
focusing efforts to develop a new gold standard based on nucleic acid amplification test
(NAATs), including multiplex PCR for genital ulcer disease, and identifying laboratories
where specimens can be readily submitted also holds merit: the wider availability of
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multiplex PCR testing is not only important to identify H. ducreyi, but also other conditions,
like primary syphilis, which also suffer current diagnostic issues. Finally, investigation of
alternative surveillance strategies to monitor the national burden of chancroid could be
explored, such as use of administrative claims data (e.g., ICD-10 codes); however, rigorous
evaluation of the alternative methods to understand strengths and limitations would be
needed prior to implementation.

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References
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Figure 1: Number of reported chancroid cases — National Notifiable Diseases Surveillance

System (NNDSS), United States, 1943–2020*
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TABLE 1.

Number and percentage of chancroid case notifications, by demographic characteristic (N = 81) — National
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Notifiable Diseases Surveillance System (NNDSS), United States, 2011–2020*

Cases

n %
Case status
Confirmed 43 53
Probable 21 26
Suspect 16 20
Unknown 1 1
Sex
Male 48 59
Female 33 41
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Unknown 0 0
Race/ethnicity
Non-Hispanic White 23 28
Hispanic/Latino 21 26
Non-Hispanic Black 15 19
Non-Hispanic Multiracial/Other 3 4
Unknown 19 23
Age, years
<15 1 1
15–19 16 20
20–24 23 28
25–29 18 22
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30–34 6 7
35–39 7 9
40–44 2 2
45–54 3 4
55+ 5 6
Unknown 0 0
Region
Northeast 16 20
Midwest 8 10
South 24 30
West 33 41
Unknown 0 0
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HIV status
Positive 0 0
Negative 11 14
Unknown 70 86
Sex of sex partners among male cases (n = 58)

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Cases

n %
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Male partners only 2 3

Female partners only 4 7
Male and female partners 0 0
Unknown 52 90
Exchanged sex for drugs or money (past 12 months)
Yes 0 0
No 10 12
Unknown 71 88
Injection drug use
Yes 0 0
No 7 9
Unknown 74 91
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*
Preliminary 2020 data reported as of September 16, 2021.
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